TABLE2 Indications for Laparoscopic Adrenalectomy for Benign Disease

With increasing worldwide experience with laparoscopic adrenalectomy, pheochromocytoma is no longer considered a contraindication to laparoscopic surgery.

Patients who may not tolerate an open operation are generally poor candidates for laparoscopic adrenalectomy.

Aldosterone secreting adrenal gland, adenoma, or unilateral hyperplasia Cushing's syndrome secondary to adrenocortical adenoma Nonfunctional adrenal mass <8 cm with negative metastatic workup Nonfunctional adrenal mass <8 cm with progressive growth on CT or MRI Adrenal pheochromocytoma (benign) <8 cm

Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging.

TABLE 3 a Selected Laparoscopic Adrenalectomy Series

Author

No. of cases

Age

Approach

OR time (min)

EBL (cc)

Hospital stay (day)

Conversion/ rate

Complications

Prager (17) (2004)

102

Transperitoneal

-

-

-

5/102

2 Blood transfusion, 1 ventral hernia,

1 Peri renal hematoma

MacGillivray (18) (2002)

60

-

Transperitoneal

183

63

2

0/60

Valeri (19)

91

-

Transperitoneal

92-148

-

3.5

2/91

2 Postoperative hemorrhage, 1 port site

bleed

1 UTI, 1 death from myocardial infarction

Kebebew (20) (2001)

176

-

Transperitoneal

168

-

1.7

0/176

5.1%

Lezoche (21) (2001)

216

45.9

149 Transperitoneal

100

-

-

4/216

1 Death, 1 hemoperitoneum, 1 wound infection

67 Retroperitoneal

Salamon (22) (2001)

115

49.3

115 Retroperitoneal

118

77

4

1/118

3.5% Intraoperative

12.1% Postoperative

Guazzoni (23) (2001)

161

39.4

Transperitoneal

160

-

2.8

4/161

5.5%

Suzuki (24) (2001)

118

51.7

78 Transperitoneal

171

96.3

-

6/118

2 Paralytic ileus

40 Retroperitoneal

4 Shoulder tip pain

Soulie (25) (2000)

52

46.9

52 Retroperitoneal

135

80

5

1/52

5.7% Intraoperative

11.5% Postoperative

Mancini (26) (1999)

172

-

Transperitoneal

132

-

5.8

12/172

8.7%

2 Deaths

Schichman (27) (1999)

50

54

Transperitoneal

219

142

3

0/50

10%

Winfield (28) (1998)

21

52.2

Transperitoneal

219

183

2.7

0/21

1 Subcutaneous bleed

2 Pneumothorax

1 Pulmonary edema

Yoshimura (29) (1998)

28

42

11 Transperitoneal

375

370

2.7

0/28

4 Blood transfusion

17 Retroperitoneal

4 Subcutaneous emphysema

2 Postoperative bleeding

Chee (30) (1998)

14

46.2

8 Transperitoneal

135

Min

3

0/14

1 Pneumonia

6 Retroperitoneal

Gagner(31) (1997)

100

46

Transperitoneal

123

70

3

3/100

12% 3 DVT, 2 pulmonary embolus

Gasman (32) (1997)

23

49.6

23 Retroperitoneal

97

70

3.3

0/23

1 Postoperative hematoma

Terachi (33) (1997)

100

-

Transperitoneal

240

77

3/100

-

Rutherford (34) (1996)

67

54

Transperitoneal

124

-

5.1

0/67

3 DVT, 2 pulmonary emboli

1 Port site hernia, 1 postoperative bleed

/Average

47.1

153.5

98.6

41/1669(2.5%)

Abbreviations: OR, operating room; UTI, urinary tract infection; DVT, deep vein thrombosis; EBL, estimated blood loss.

rate was 3%, average length of hospital stay was three days or less, and postoperative morbidity was experienced by 12% of patients.

In the largest reported series, a combined experience of surgeons in Italy and the Netherlands by Lezoche et al. (21), a total of 216 laparoscopic adrenalectomies were performed using the anterior transperitoneal, lateral transperitoneal, or the posterior retroperitoneal approaches. The average operating time of all approaches was 100 minutes with a conversion rate of only 1.9%. Average hospital stay for all approaches was three to four days.

Studies comparing laparoscopic and open adrenalectomy have been conducted to determine if there are significant benefits provided by the laparoscopic approach (28,29,34-40). Overall, laparoscopic surgery requires longer operative time, particularly early in the learning curve. However, operative time decreases with increasing surgeon experience. In addition, the laparoscopic approach provides less blood loss, significantly less postoperative narcotic use, overall shorter hospital stay, and a faster return to normal activity. In one study, the costs of a laparoscopic and open adrenalectomy were comparable (41).

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